NCC212265_NOI Application_20210415

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/13/2021 7:48:23 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 4/14/2021 4:16:12 PM (Review- Construction NOI 50192)
• The task was assigned to Garcia, Lauren V by round robin distribution 4/13/2021 7:49 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 15, 2021 5:00 PM.
The priority is: High 4/13/2021 7:49 PM
Submit by Selkane, Aziza 4/15/2021 10:44:59 AM (Payment Verification for NCC212265)
* Alexandra Hecht
• Selkane, Aziza assigned the task to Selkane, Aziza 4/15/2021 10:42 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 26, 2021 5:00 PM. The
priority is: High 4/14/2021 4:17 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting
f• No
an NOI that was
r Yes
rejected before?
1a. Project Name *
Stony Knoll Access Road
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all Rios associated w ith this project.
Number(s) (PIN) 590300719137, 590300729489, 590300823578,
590300921352,591300112253,591300006143
2. County* Surry
3. Highway or Street Old Wagon Trail
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Dobson
5. State * NC
6. Zip Code* 27017
7. Latitude* Enter the latitude in decimal degrees
36.2983
8. Longitude * Enter the longitude in decimal degrees (MJST be negative)
-80.6669
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin*
04/19/2021
Estirrated Construction Project Start Date
10. Date to End *
05/19/2021
Estinated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial C]assification for Developrrent
12. Acres to be
7.00
d istu rbe d *
(including off -site borrow and waste areas)

13. Total site area 190.60
(acres) *
14. Post- 1.59
construction (Estinated)
impervious area
(acres) *
NCC Project NCC-SURRY-2021-Stony Knoll Access Road
Tracking ID Assignedautonatically
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Davenport Creek
Waterbody* Narreof waterbody into which stornwater runoff will discharge
15b. Waterbody 12-63-18
Index No. * NCWaterbody Index Nunber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional West Double Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 12-67-1
Index No. NC Waterbody Index Nmber
15e. Additional Waterbody name
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Narrber
Index No.
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
F2rnittee Inforrration - Legally Fbsponsible Entity and Individual
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should be the same person as listed in THIS SECTION, or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who owns or operates the construction activity, such
as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,
Section B, Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Legally Pesponsible Entity
Name * S%tinerton Builders
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * David
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Grubb
It Corporation, enter Pbegistered Agent Last %rre
3b. Title VP Operations Manager
4. Permitee E-mail Alexandra. [e-mail]
Address*
5. Permittee 760-520-5415
Telephone No.*
6. Permittee Mailing Street Address
Address* 16680 WEST BERNARDO DRIVE
Address Line 2
City State / Frovince / Fbgion
San Diego CA
Fbstal / Zip Code Country
29127 United States
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
16680 WEST BERNARDO DRIVE
Address Line 2
City
State / Frovince / Faegion
San Diego
CA
Fbstal / Zip Code
Country
29127
United States
8. Type of
ONnership is only individual if an individual is naned in B.1. above.
Ownership*
Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Jennifer
Contact - First
Name *
2. Primary Site
Kirby
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
858-357-5006
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
16680 WEST BERNARDO DRIVE
Address Line 2
City
San Diego
Postal / Zip Code
927127
8. Consultant Name
(Optional)
Jennifer Lester
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-677-2069
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
760-520-5415
Default is legally responsible person telephone
State / Province / Region
CA
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................................................................................................__
1. Date E&SC Plan 04/06/2021
Approved *
2. E&SC Plan Project SURRY-2021-013
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Winston-Salem (WSRO)
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan SURRY-2021-013_20210406_Approval_Express.pdf 3.68MB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 201VB)
Access Road —Site Location. pdf 14.73MB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification Sig ned-NCG01-eNO1-Certification-Form-20210412-
Form 819.52KB
Access Road.pdf
Mast be FDFformat
This is an Express r No
Review Project* F Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 I am the person responsible for the construction activities of this project, for
satisfying the requirements of this permit, and for any civil or criminal penalties
incurred due to violations of this permit.
rJ The information submitted in this NOI is, to the best of my knowledge and belief,
true, accurate, and complete based on my inquiry of the person or persons who
manage the system, or those persons directly responsible for gathering the
information.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ I hereby request coverage under the NCG010000 General Permit and
understand that coverage under this permit will constitute the permit
requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Specify if you are:* IT The Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
owns or operates the construction activity, such as a president, secretary, treasurer, or vice president, or a manager
that is authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
Type Name * David Grubb, Jr.
Title VP Operations Manager
Organization Legally Plesponsible Entity
Svvinerton Builders, A Corporation
Date * 04/13/2021

F. Tracking and COC Info
NOI Tracking No. 50192
NC Reference No.
NCG01-2021-2265
Uses 'count_nurber' variable (increrrented by SP)
Certificate of
NCC212265
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 2265
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC212265-2021
Invoice Due Date 5/14/2021
Initial Fee $ 100.00
Invoice Status OPEN